Prioritization & Delegation Practice Test #6: Mixed Prioritization

Answer: A. A client with a respiratory rate of 36/min who is breathing on their own

Rationale: In a mass casualty event, triage aims to do the most good for the most people, so the order is different from a normal day. In START, a client who is breathing with a respiratory rate over 30/min is tagged red (immediate) because quick treatment can save that life. Other red findings are no radial pulse or a capillary refill over 2 seconds, and not being able to follow simple commands. The client who can walk is tagged green (minor). The client who still is not breathing after the airway is repositioned is tagged black (expectant or deceased), because resources go to those who can be saved. The client with a fracture who is breathing normally, has a pulse, and follows commands is tagged yellow (delayed). Some regions use other systems, such as SALT, so follow the local disaster plan.

Answer: C. The first dose of an IV antibiotic for a client with new fever, chills, confusion, and a blood pressure of 88/50 mm Hg

Rationale: This client has signs of sepsis with low blood pressure and new confusion, which can quickly become septic shock. Starting antibiotics early is one of the most important treatments, and sepsis guidelines recommend giving them as soon as possible, ideally within 1 hour when septic shock is likely. Facility sepsis protocols set the exact steps, such as drawing blood cultures before the first dose when this does not cause a delay. The metoprolol is due, and the client's vital signs show it is safe to give, but it is not time-critical. Mild headache pain and a routine acid-reducer can wait a few minutes without harm.

Answer: B. Ineffective airway clearance, shown by coarse crackles, a weak cough, and an oxygen saturation that has dropped to 90%

Rationale: Two rules help here. First, airway and breathing come before other needs. Second, an actual problem that is happening now usually comes before a risk problem that has not happened yet. Crackles, a weak cough, and falling oxygen saturation mean the client is not clearing secretions, and an older adult after surgery is at risk for pneumonia and low oxygen. The nurse should help the client sit up, cough and deep breathe, use the incentive spirometer, and report the change. Infection is a risk problem. Impaired mobility is real but is not as urgent as breathing. Discharge teaching is important but comes last.

Answer: D. A client who started lisinopril last week and now has swelling of the lips and tongue

Rationale: Swelling of the lips and tongue in a client taking an ACE inhibitor such as lisinopril suggests angioedema. The swelling can spread to the throat and block the airway, so this is an airway emergency. The nurse should call this client first and direct them to emergency care (call 911) right away, and the drug should be stopped. Angioedema can occur at any time while taking an ACE inhibitor, not only at the start. The nosebleed has stopped, but the client on warfarin should still be followed up, for example with an INR check. A glucose of 180 mg/dL and a refill request are not urgent.

Answer: C. A client whose face began drooping and whose speech became slurred 40 minutes ago

Rationale: Sudden facial droop and slurred speech are signs of a stroke, and stroke care is time-critical because brain tissue is lost every minute. Knowing when the symptoms started matters: under current American Heart Association and American Stroke Association guidelines, clot-busting medication can be given to eligible clients within a set time window, commonly up to 4.5 hours from when they were last known to be well. The hospital's stroke protocol decides who is eligible. The client with kidney stone pain needs pain relief soon, but is stable. The ankle injury and the alert, playing child with a fever can safely wait.

Answer: A. A 3-year-old who is drooling, sitting upright leaning forward, and speaking in a muffled voice

Rationale: Drooling, sitting upright and leaning forward (tripod position), and a muffled voice are warning signs of epiglottitis, which can block the airway completely and suddenly. The nurse should keep the child calm and upright, ideally with the parent, have emergency airway equipment ready, and get help. The nurse should not look in the child's throat with a tongue blade or take a throat swab, because this can cause the airway to close. The child with croup is resting quietly with good oxygen saturation. The ear infection and the mild diarrhea with moist mucous membranes need care but are not airway emergencies.

Answer: D. Put the end of the chest tube about 2 to 3 cm (1 inch) under the surface of a bottle of sterile water or saline

Rationale: Putting the open end of the chest tube a short distance under sterile water or saline makes a quick water seal. Air can then leave the chest but cannot be pulled back in, which helps prevent the lung from collapsing. The nurse then sets up a new drainage system, assesses the client's breathing and oxygen saturation, and notifies the provider. Facility policy may describe other steps, such as reconnecting quickly if the ends are not contaminated. Clamping a chest tube can trap air in the chest and cause a tension pneumothorax, so it is not done unless a prescription or policy allows it for a specific reason. Waiting for a call wastes time, and the nurse never removes a chest tube in this situation.

Answer: B. Give 15 grams of a fast-acting carbohydrate, such as 4 ounces (120 mL) of fruit juice, and recheck the glucose in 15 minutes

Rationale: A client who is awake and can swallow safely is treated by mouth with a fast-acting carbohydrate, then the glucose is rechecked in about 15 minutes and treatment is repeated if it is still low. The American Diabetes Association describes this as the 15-15 approach, and most facilities have a hypoglycemia protocol that lets the nurse treat right away. Once the glucose comes up, the client should eat a snack or meal. Glucagon or IV dextrose is used when the client cannot swallow safely or is unconscious. Giving insulin now would lower the glucose even more. Waiting for a call delays treatment of a problem that can quickly lead to seizures or loss of consciousness.

Answer: A. A client whose last drink of alcohol was 2 days ago, who has hand tremors, a heart rate of 124/min, a blood pressure of 172/100 mm Hg, and says there are bugs on the wall

Rationale: This client shows signs of severe alcohol withdrawal: a fast heart rate, high blood pressure, tremors, and seeing things that are not there. These signs often appear about 48 to 72 hours after the last drink and can progress to withdrawal seizures or delirium tremens, which can be life-threatening. The nurse should assess now, use the facility's withdrawal scale (such as CIWA-Ar), give the prescribed medication, and keep the client safe. This is a physiological problem, so it comes first. The other three clients need follow-up, but none has an unstable physical finding right now.

Answer: C. A client at 34 weeks with a blood pressure of 164/112 mm Hg on her home monitor, a headache that will not go away, and spots in her vision

Rationale: High blood pressure with a headache that does not go away and changes in vision are signs of preeclampsia with severe features. The American College of Obstetricians and Gynecologists treats a blood pressure of 160/110 mm Hg or higher in pregnancy as severe range, and it should be treated promptly because of the risk of stroke, seizures (eclampsia), and harm to the baby. This client needs to be evaluated right away, per the facility's obstetric protocol. Morning nausea with fluids staying down is common early in pregnancy. Ankle swelling that goes down overnight is expected. Irregular tightening that eases with walking sounds like Braxton Hicks contractions.